Q:  Can Zyprexa be Used as a Temporary Add-on to Lamictal for Rough Spots?

Can Zyprexa be added to Lamictal temporarily to get a person thru a rough spot?  Lamictal seems to work fairly well for a period of time but then there's sleeplessness and increasing emotional volatility.  Since my daughter is a single parent and is trying to hang on to a job it is essential that something work rapidly.  Small doses of ritalin seem to help with the inability to concentrate at those times but sleeplessness is still a big problem.  Thank you for your help?

 
Dear Carol --

Yes, adding olanzapine (Zyprexa) to lamotrigine (Lamictal) temporarily -- "as needed" -- is a common strategy. This avoids some of the risks, particularly weight gain and other metabolic changes, of olanzapine.  And for many people, such an add-on medication is not necessarily on a routine basis. 

However, if this "as needed" additional medication is used very frequently, this might indicate that there is "cycling" going on which is not being completely prevented by lamotrigine alone.  When that is the case, I will usually look for an additional mood stabilizer (non-medication* or pharmaceutical), rather than wait around for symptoms to show up and then try to chase after them.

*e.g."social rhythm therapy"; increased physical activity, which I think has mood stabilizing properties -- and is certainly a good idea, as long as people can tolerate it and be careful with it, even if it doesn't do more than just prevent depressions, which I think it quite clearly can do; and perhaps even "dark therapy", which you can think of as sort of the opposite of light therapy, which we know is an antidepressant in some kinds of depression.  And of course, trying to remove destabilizing factors, like regular sleep deprivation; alcohol and other substance use; and huge emotional stresses (in the rare cases where people can actually control such things), is also a good idea in this context.

If sleeplessness is routinely a problem, then a treatment which addresses that (again, non-medication or pharmaceutical) could be helpful even if it was not a "mood stabilizer" as such.  We should think of exercise again in this role; or relaxation training; or perhaps the dark therapy idea.  After that, we consider lorazepam and its cousins; or zolpidem (Ambien) and its cousins; and then medications with greater potential negative consequences, but often more assured effects, such as quetiapine (Seroquel).

With luck, treating the sleep might address the "inability to concentrate", and thereby avoid the need for the stimulant medication (methylphenidate/Ritalin) -- which ironically could contribute to sleep disturbance and potentially be causing some of the problems, a medication-induced chicken and egg problem.  Hopefully that is not a factor in your daughter's case, and as usual, any medication or other treatment changes should always be discussed with the treating physician, never acted upon on one's own.  A good physician will already have considered this chicken/egg issue and may have specific reasons for proceeding with such a treatment approach.

I hope something in there proves to be useful.

Dr. Phelps

Published April, 2009